The Art of the Transfer (part 1)

One of the problems with EMS today is that it involves a bait-and-switch.

From the outside, it’s not widely understood what the work involves. There’s a vague idea about flashing lights and saving lives, but that’s about all the public knows. So, enterprising young men and women take the class, get the training, find a job, and quickly discover that EMS from day to day isn’t quite what they had in mind.

Nowhere is this more apparent than for the EMT-B. For him, in many areas, most or all of the available work involves not emergency 911 response, but non-emergent patient transfers. Patients travel from home to hemodialysis centers, from nursing homes to doctor’s offices, or from hospitals to rehab facilities. Sometimes these are patients who need oxygen therapy or airway management; sometimes they are medically unstable and need close monitoring (although these patients often travel by ALS); but most often, they’re simply people who can’t easily stand or walk. If due to age or disability you’re unable to climb into a car or shuttle, and can’t safely transfer yourself to and from a wheelchair or sit in it, then you need to travel from place to place in a bed — and ambulances are the only traveling “bedmobiles” out there. Well, ambulances and hearses.

Routine transfers can get old. Real old. Maybe you’re looking for excitement. Maybe you’re looking to make a difference. Maybe you just want to use your skills or activate some neurons. Whatever the case, it’s easy to feel like bringing an endless parade of old people to their eye appointments is neither “emergency” nor “medical” even if it is a service.

Nevertheless, for many of us it’s an unavoidable part of our day. So it’s worth making the most of it.

A Classroom in the Ambulance

Transfers might be boring. But boring’s a good way to start out. There’s no better way to learn how to be an EMT.

My first job in this business was in a system doing 911 coverage almost exclusively. This seemed like a great opportunity, especially in an area (Northern California) where EMTs in the private sector were rarely able to work emergencies.

In retrospect, though, it was the wrong way to start. I walked in the door with absolutely no idea of how to do this job, and was immediately thrown into the field with no learning curve. I was expected to assist the medic, drive the ambulance, check the equipment, manage communications, and of course handle any BLS care. This was fresh out of EMT class, where I had no idea how to do any of that, and most of what I did know is not what was needed. And guess what? Every call was an emergency. Admittedly most “emergencies” are not exactly world-ending, but there were still stakes involved, which meant that being useless was bad for the patient, bad for my medic, and bad for me — because with the pressure on, it was difficult to relax and make the necessary “learning mistakes.”

My next job was in a service where almost 100% of our work was routine transfers. Although this could be mind-numbing, I quickly realized how much of a better learning environment it was. Because in nearly every case, the patient in front of me was not having any acute problem, my assessment could be a total blind-man’s fumble and there wouldn’t be any adverse results. That’s not to say that you’ll never be in a position to take action — but it’s rare.

On a 911 response, you’re the patient’s initial point of entry for the health care system. Before today, there was no problem, at least not from this particular episode. Now there’s something new that needs to be addressed, and you’re deciding how that will happen. The answer might be easy, but it’s still being made.

On a transfer, the patient’s course of care has already been planned and initiated. Their problems are diagnosed, their treatments are underway. Your responsibility isn’t to set anything into motion, but merely to ensure that there’s no deviation from the intended path. This requires learning the patient’s current baseline — which may be very sick — so you can note any new changes, and learning what their current plan is (perhaps a discharge back to their home, which will require a stair-chair carry to get inside), so you can facilitate it as best you can.

Take some vitals. Check pupils, feel skin, listen to breath sounds. Listen to their story. You’re doing these things as a matter of course, because you’re supposed to, in the midst of friendly chit-chat — but you’re also practicing all of your foundational skills. In the off chance of anything unusual, you’ll hopefully find it. But in the mean time, you’re turning yourself into a good EMT, so in the future when you do start running emergencies, you’ll be ready. Do more than you need to, because the time to figure out the tricks of taking a thigh blood pressure is when it doesn’t matter, not when it does.

Look, Roy, these gomers have a terrific talent: they teach us medicine. You and I are going down there and, with my help, Anna O. is going to teach you more useful medical procedures in one hour than you could learn from a fragile young patient in a week. . . . You learn on the gomers, so that when some young person comes into the House of God dying . . . you know what to do, you do good, and you save them. (76)

Tune in next time for more on the fine, fine art of squeezing juicy goodness out of each transfer you get.